It’s the platform, stupid

I read with interest a recent article by my favorite health care reporter, Joe Conn, who has long time interest in the commercial success of the VistA Electronic Health Record system developed by the VA.

VistA has an incredible, well described impact on the clinical and
system peformance of the VA. Given its availability through the Freedom
of Information Act, it can and should seriously be considered as a
potential solution for government-based health care information
technology. I mean, why not? The several billion dollars already
invested, and the several billion dollars already wasted on
alternatives, would hopefully help the new administration come to their
senses to realize the development of a common platform for all
government related health IT would make good business sense.

In the past, this notion has been fought by the other departments
who have “special” needs (NASA needs their own system, Indian Health
Services has a different focus, DoD needs increased mobility, etc).
Whatever the “smoke screen” reason is, the fact of the matter is that
these departments are protecting their turf and their budget. However,
all of these entities have some basic functionality that is required of
any basic system (Patient Information Management, Laboratory, Pharmacy,
Radiology, Notes, etc) that are shared across the departments. This
“basic system” should be conceived of as the core platform from which
the modular functionality can be built. Everyone develops to the common
core and creates “apps” (modules) that tie into the generic platform
but serve specialized needs.

I don’t think anyone would argue with the success of the Facebook platform, nor the various app extensions that have been automonomously developed by its users? Would anyone argue against the Apples iPhone platform and App
store framework? Well, it seems that VistA has the potential, certainly
within the Federal Health care space*, to become the defacto platform
from which to build.

But what about the private sector? Does VistA have a similar
opportunity.  Among many issues that prevent the widespread adoption of
VistA in the commercial sector, one unfortunately persistent problem is
what “version” of the platform should we use (WorldVistA, OpenVista, vxVistA, or flavorofthemonthVistA). While this is irritating and groups like World VistA and the VistA Software Alliance
have been wrangling with this issue since 2002, it belies a more
fundamental problem with the widespread adopting VistA  – it actually
isn’t (or as currently constructed) a viable platform.

What? Heresy? What say you?

The inestimable foundational system from which VistA is based is MUMPS. MUMPS is both a programming language and a database all conjoined into one ugly mess that only a mother could love.
The story of MUMPS, and its use within the VA is quite fascinating, and
the religious fervor of its faithful and its detractors is epic.
However, then nature of MUMPS makes it actually quite hard to
“modularize” VistA. You can’t really cleanly delineate between parts
and subparts, from routines and runtimes, and most importantly
demarcate between the notion of a “platform” and the specialized apps.

This has led to commercial challenges in extending the system,
having to swallow the software “whole” without the inability to easily
integrate other IT investments, or the limited ability of third party
development shops to rally around the platform by creating supporting
apps that meet critical market feature/functionality needs. Until this
problem is solved – until we get to some layers of abstraction within
the technology stack – VistA will continue to bump along in its
adoption, we will continue to be mired in forking conversations, and
bogged in difficult licensing issues to work out that prevent true

I am hoping someone, anyone, who is interested in VistA’s commercial
success will be able to create the platform/app separation that I would
argue is required for VistA’s long term commercial success.

* There are specific reasons why VistA can and should become the de facto standard within the Federal Health System:

  1. The VA is the largest health care system in our country with
    over 160 medical centers and 1,300 clinics all utilizing essentially
    the same software.
  2. All the current information technology systems are derived from
    it (Both the DoD and IHS use a variation of VistA) and therefore share
    significant architectural similiarities.
  3. VA has been by far the most successful historical in achieving
    clinical transformation through the use of information technology;
    although IHS is by far the most innovative now health care IT branch of the Federal Health System thanks to the vision of CIO Terry Cullen, MD.

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6 replies »

  1. To Billy Jackson,
    Thanks for your note . . . please see my followup post:
    I am actually a huge fan of MUMPS, given its commercial success and real time performance in the largest implementations in health care IT. However, to become even more pervasive I want to see MUMPS based systems adopt some of the lighter weight, agile, flexible new tools to continue to give vitality to this proven technology.
    To JFS,
    Love the quote, “Its a dog and an old one at that”. It belies a very important point. VistA in and of itself does not measure up to the current commercial offerings and could well be classified as a “dog” at first blush. However, on closer inspection, the “systemness” (degree of integration) of VistA is what has enabled the VA Health Care “System” to truly function as an intergrated health system. VistA was absolutely critical as an enabler to help transform the VA from “Born on the 4th of July” to “Best Health Care System” in America. The ability to measure comprehensively, monitor systematically, and then to improve outcomes objectively has been the crux of their success.
    To Russ,
    You are absolutely correct! While I absolutely love Epic, I have to wonder if the $185 M NYU is spending on their implementation really is worth the 10X+ price tag for a comparable implementation of VistA. Is EPIC 10X better? I don’t think so . . . but HIMSS would never tell you that. Furthermore, no one else benefits from that investment given the proprietary nature of the close system. Why not spend the same $185M on enhancing an already open source system and share the code and collective learnings with others? Isn’t this the essence of the “shared responsibility” that we keep hearing so much about?
    You will see more on this “collective intelligence/collaboration” soon.

  2. Hi Scott, I love the points you make in regards to architecture being the foundation for agility! Your point about mumps though leaves a pretty big opening for folks who would argue that it’s not the weak platform that you profess. Specifically that there are still multiple commercial healthcare apps, and some big ones too, that still run on mumps. I can think of McKesson (STAR ADT/Billing/Radiology) and Antrim (now Cerner) lab. Last but not least Cache, the newest incarnation of mumps is the engine for GE Centricity Business that’s still implemented as a bunch of globals and one letter M commands. You’d also have to include Epic in this bunch and that’s clearly a strong commercial offering. In fact I often think I hear loud kirby vacuum sounds when trying to hire Cache talent due to all of the Epic implementations under way. In the case of Epic and Centricity Business they do use web based front ends so I suppose the platform and application is demarcated although I’d argue not as well as a J2EE, .net or other more contemporary stacks.
    Thoughts? Does mumps have a place in healthcare IT 10 years in the future???

  3. Russ’s comments about VistA and HIMSS are right on. We need to start demanding that government agencies and other organizations stop the turf-protecting, which is only costing the industry millions of dollars and incompatible EHR implementations. VistA has a lot to offer the industry and a lot of potential. Perfect? Far from it, but others could learn a lot from its implementation within the VA system.

  4. Conversely if you want to study a huge Government HIT system to learn what NOT to do with HIT, study the DoD’s AHLTA. It is an abyssmal disaster.Niko Karvounis from HealthBeat Blog and in an article he did for Mother Jones tells the sad tale of this monumental failure.Even the DoD itself is becoming more transparent about AHLTA’s failures.What a mess.
    Dr. Rick Lippin

  5. Scott,
    Thank you for an excellent post elevating a discussion of VISTA! Your article clearly articulates the advantages to the VISTA platform:
    1. A well developed core system -Patient Information Management, Laboratory, Pharmacy, Radiology, Notes,
    2. Safety and Quality features are bundled including machine readable technologies (Bar code & RFID)
    3. VISTA system is in place at the national level spanning the United States, operational and fairly efficient managing upwards of 25 million veterans with scalability to handlemuch more. There is no commercial equivalent to this.
    4. US Taxpayers need to realize the value of their investments and leverage that power across the fragmented whole…
    From a historical perspective as the former Patient Safety Officer for HIMSS.org , VISTA (free) downloads were made available to ambulatory physicians in late 2005. HIMSS chose to ignore the opportunity to evaluate VISTA despite repeated proposals. When industry leaders, albeit self-proclaimed, balk at opportunity like this its usually about protecting their turf and this case is no different.
    As the coin turns, HIMSS now offers itself up as a a leader in Government Healthcare policy with an agenda to shape outcomes at the federal level, presenting itself a a source for educating in the federal health sector. However no mention of VISTA or implementaions are uttered by the so-called industry leader. I do not believe this avoidance is based upon the problems your article identified as a conjoined programming language and database. complexity. HIMSS folks, at the business level, would not understand the problems described, HIMSS is staffed by non-technical and non-clinical personnel. Earlier, HIMSS was very clever to spwan CCHIT as a certifying body for vendors of commercial EHR’s demonstrating again how money buys influence and power at the national level while working against the needs of the American people. CCHIT has not evaluated VISTA and neither has HIMSS because it defeats the economic model of “riches for the few at the expense of the many”.
    Technology has advanced and conversion of MUMPS to C++ is possible with several projects underway for several years. Taking the best of what VISTA has to offer and making it useful for the general public who paid for this powerhouse presents itself as an interesting opportunity to the private sector. What is needed is real leadership and advocacy in the area of continued development toward a standardized electronic health care record for every American and not continued advocacy of fragmented healthcare driven by niche private and commercial interests.
    A possible method might consider the elimination of 501 (c) (6) tax-exempt status to organizations who continually stall the evolution of real HIT deployment for their own micro-economic gain. Why should the taxpayers subsidize organizations that impede the roll-out of what they have already paid for, especially in this time of need with population healthcare demand at approximately 300 million people? Taxpayer subsidies for such counter-currents are wasteful, disruptive and ethically wrong and only serve to profit a very small segment of the population.
    Its time to end the free lunch for the few and put the needs of the many first. The VISTA platform can handle the challenge. Lets make it economically attractive to complete an implementation at the national level for every American.
    Russ Bourke, RN, MBA

  6. VistA in and of itself is not a success. Overall it is a dog, and an old one at that. The success is the VA system and VistA implementation within its unique environment.
    One man’s opinion.